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Form from HIS OpenVistA

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  1. 2/23/12
  2. 8/7/14
  3. 8/7/14
  4. 6/26/15
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June 26, 2015

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Creative Commons BY-NC 3.0 Legacy
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H and P or consult specialty

HIS

  1. StudyEvent: HIS
    1. HIS
H and P or consult specialty
HISTORY OF PRESENT ILLNESS
REVIEW OF SYSTEMS
PAST HISTORY
Female Specific History
FAMILY HISTORY
SOCIAL HISTORY
ALLERGIES
No Known Allergies
MEDICATIONS
PHYSICAL EXAM - General
°C
beats/min
/min
mmHg
kg
PHYSICAL EXAM - HEAD
HEAD (Normocephalic, atraumatic)
PHYSICAL EXAM - EYES
Auge
Physical Exam - Ears, Nose, Throat
Ear canals patent. TM's intact. Nares patent and pink without epistaxis. Mucosa pink. No pharyngitis. Natural dentition.
Physical Exam - Neck
Hals
Physical Exam - BREAST
symmetric without masses
Physical Exam - CHEST
normal for inspection, percussion, palpation, and auscultation of the lungs.
Physical Exam - HEART
PMI at 5th intercostal space, mid clavicular line, normal S1,S2 without murmur or gallop
Physical Exam - VASCULAR
Pulses present and equal bilat.
Physical Exam - ABDOMEN
soft, flat, nontender with normal bowel sounds. no organomegaly, no ascites, no palpable mass, no hernia.
Physical Exam - GENITOURINARY/RECTAL: MALE
Physical Exam - GENITOURINARY/RECTAL: FEMALE
Physical Exam -MUSCULOSKELETAL
Physical Exam - EXTREMITIES
Physical Exam - LYMPHATIC
no adenopathy
Physical Exam - SKIN
Inspection and palpation of skin and subcutaneous tissue reveals no acute rashes, lesions, or induration.
Physical Exam - Wound and Incision Care
UNDERMINING Wound
TUNNELING Wound
ODOR: Before Cleaning
ODOR: After Cleaning
Physical Exam - NEUROLOGIC
Oriented x 3, cranial nerves 2-12 intact, no gross sensory or motor deficits, reflexes symmetric, no cerebellar signs, no involuntary movements
Score normal
Concentration normal
Cranial nerves normal
PSYCHIATRIC
Alert, oriented to person, place, and time, judgement and insight good, recent and remote memory intact, normal mood and affect.
Laboratory Results
Laboratory results reviewed
Radiology Results
Radiology results reviewed
ASSESSMENT
acceptable for surgery
progressing well
stable medically
PLAN
Continue Home Regimen
Continue Home Meds
Continue Chemotherapy
Continue IV Antibiotics
Continue PO Antibiotics
Deep venous thrombosis prophylaxis
O2 Protocol
Follow Up X-Rays
UTI treatment
Monitor Blood Pressure and Heart Rate
Monitor Diabetes Mellitus
Accuchecks AC & HS
Accuchecks Q6H
Sliding Scale Regular Insulin
Check Follow Up Labs
Appreciate following patient with you